Corrective Action Plans

Noncompliant Buy America Procurements - Transit - MDT - The Montana Department of Transportation is strengthening internal controls and ensuring full compliance with federal requirements for procuring public transit vehicles. The Transit Section and the Procurement Unit are jointly developing comprehensive procedures that clearly define roles and responsibilities, update procurement checklists, and establish a centralized location for maintaining complete procurement files. Responsible Party - Kimberly Doherty, Accounting Systems Supervisor, Montana Department of Transportation Target Implementation Date - 12/31/2026

Inadequate Suspension and Debarment Verifications - Transit - MDT - The Montana Department of Transportation concurs with the finding. A. The Transit Section and Procurement Unit are jointly developing comprehensive procedures that clearly define roles and responsibilities, update procurement checklists, and establish a centralized location for maintaining complete procurement files. These updated procedures will be completed by the end of calendar year 2026. B. The Procurement Unit and the Legal Office began working together in July 2026 to review all templates, clauses, and federal requirements. This review will be ongoing to ensure compliance with all state and federal regulations. Responsible Party - Kimberly Doherty, Accounting Systems Supervisor, Montana Department of Transportation Target Implementation Date - 12/31/2026

Noncompliant Annual Reporting Controls - ESSER - OPI - The Montana Office of Public Instruction concurs with the finding. The grant is closed, and the temporary grant-funded staff are no longer with the agency. Moving forward, new grant managers will receive clearer direction on the agency’s internal controls. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026

Condition During testing of cash disbursements, the audit team was unable to locate adequate supporting documentation for selected transactions sufficient to determine whether the costs charged were allowable and the activities were allowed under the applicable federal award(s). Documentation such as invoices, receipts, contracts, approvals, or evidence linking the expenditure to an allowable activity could not be located or provided by the Institute. Criteria Per 2 CFR § 200.403, costs charged to a federal award must be necessary, reasonable, and adequately documented. Per 2 CFR § 200.302 and § 200.334, non-federal entities must maintain financial records, including source documentation (e.g., invoices, receipts, canceled checks, time and effort records) that support the allowability, allocability, and reasonableness of costs charged to federal awards, and these records must be retained and readily accessible for a minimum of three years. Additionally, 2 CFR § 200.404 and § 200.405 require that costs be allocable and consistently applied to allowable program activities. Cause The Institute's recordkeeping and document retention practices did not ensure that supporting documentation for cash disbursements was consistently maintained, organized, or readily retrievable. This may be attributable to insufficient internal controls over document retention, lack of a centralized filing/records system, or turnover in staff responsible for maintaining disbursement records. Effect Without adequate supporting documentation, the Institute cannot demonstrate that disbursed funds were used for allowable costs and allowed activities in accordance with the terms of the federal award(s). This exposes the Institute to the risk of questioned costs, disallowed expenditures, required repayment to the funding agency, and potential findings of noncompliance in future audits. It also limits the Institute's ability to demonstrate accountability and stewardship over federal funds. Recommendation We recommend that the Institute strengthen internal controls over cash disbursements to ensure supporting documentation (invoices, receipts, approvals, and evidence of allowable activity) is obtained and retained for every transaction prior to disbursement. The Institute should implement a centralized, organized recordkeeping system (physical or electronic) for disbursement documentation, with clear responsibility assigned for maintenance and retrieval. The Institute should also provide training to relevant staff on documentation retention requirements under 2 CFR Part 200. Management’s Response Management agrees with the finding and recommendation. The Institute recognizes that complete and readily retrievable supporting documentation is necessary to demonstrate the allowability, allocability, and reasonableness of costs charged to all awards. Management will strengthen its cash disbursement and record-retention procedures to ensure invoices, receipts, approvals, contracts, and other applicable supporting documentation are maintained for each transaction. Action Taken The Institute implemented a centralized electronic recordkeeping process for cash disbursement documentation and assigned responsibility for maintaining and retrieving supporting records. Documentation supporting the expenditure and applicable approvals are retained with the transaction records. Relevant staff have been instructed on documentation and record-retention requirements applicable to federal awards. Management will hold an annual training at the beginning of the new fiscal year available to all ERI employees.

Finding 2025-007 –Waiting List – Eligibility – Internal Control over Waiting Lists – ALN 14.871 Housing Choice Voucher Program, ALN 14.850 Low Rent Public Housing Program – Noncompliance and Material Weakness Corrective Action Plan: • Preserve a dated copy or system extract of each waiting list at material selection and offer points; • Retain applicant rank and preference information; • Document selections; • Establish a sufficient audit trail; • Reconcile written procedures with the Administrative Plan and ACOP; and • Include waiting-list records in the formal retention schedule. Person Responsible: Jennifer Oberlin, Executive Director, with oversight and approval by the Board of Commissioners, where applicable. Anticipated Completion Date: October 30, 2026

In order to avoid this situation happening in the future, instruction will be provided to all personnel emphasizing that every purchase should be made through a purchase order. This will ensure that we follow the BGCPR formal procedure and ensure better internal control is being followed. In addition, we will emphasize that no shipment should be received if such purchase is not in accordance with the specification disclosed in the purchase order. Contact Person: Purchase and procurement personnel Carlos Rivera Paul Barreras Amarilis Rodríguez (PACNA’s Project Manager) Team: Finance Team Anticipated Completion Date: September 30, 2026

BGCPR will provide additional training and guidance to Human Resources personnel to ensure consistent adherence to the internal procedures established. Contact Person: Yezaida Reyes Angel Morales Paul Rivera Team: Finance, Compliance and Human Resources Team Anticipated Completion Date: September 30, 2026

BGCPR will provide additional training and guidance to Human Resources personnel to ensure consistent adherence to the internal procedures established. Contact Person: Yezaida Reyes Angel Morales Paul Rivera Team: Finance, Compliance and Human Resources Team Anticipated Completion Date: September 30, 2026

Finding #2025-004 - Reporting; Procurement and Suspension and Debarment; Subrecipient Monitoring; Allowable Costs/Cost Principles Corrective Action Planned: Since the Finance Manager's arrival, a process has been implemented to reconcile quarterly expenditure reports submitted to the State of Michigan against the general ledger; this reconciliation has become clearer and more consistent with each subsequent period. Beginning in September 2025, suspension and debarment checks on SAM.gov are performed for every new vendor and subrecipient - owned by the Executive Director of the Center for Adult College Success for Center vendors and the Finance Manager for TalentFirst vendors, with all checks reviewed by the Finance Manager. Employee wage allocations are now supported by timesheets and documented on the monthly journal accrual e-signature form, which retains the allocation and its approval electronically. Anticipated Completion Date: Already implemented. Responsible Party: Finance Manager, with oversight by the President.

Finding 2025-002: SLFRF Record Retention Description of Finding: Elevation timecards for employees for the pay period ending 4/3/2025 were not adequately retained during the required three-year period. Statement of Concurrence or Nonconcurrence: Management concurs with the finding. Corrective Action: Management concurs with the finding. The inability to test controls in this instance was the result of a change in software for timekeeping that the clinic made during the fiscal year from Tsheets to Paycor. Quickbooks was unable to provide access to the retired system once the transition to Paycor was completed. Where the grantor has required timesheet data to be provided and submitted as part of grant reports, the information was saved and submitted. Where the auditors selected data for testing that had not been required by a grantor as part of a report, access was not able to be obtained by the Clinic in the previous system for testing. Fortunately, however, these controls were already in place in the new system and have been in continuous use since the programs inception, therefore no additional steps need to be taken to ensure compliance moving forward as compliance resulted from lack of access to test the control, not an actual process or procedure not in place. Responsible Personnel: Erin Hall, Executive Director, ehall@nclegalclinic.org, (317) 429-4130 Projected Completion Date: complete as of the date of this plan, July 15, 2026

Title: Inadequate Tenant File Documentation in MTW Housing Choice Vouchers (ALN 14.881) (Repeat of Finding 2024-005) Program Name: Moving to Work Demonstration Program - Housing Choice Voucher ALN: 14.881 Description: During tenant file testing for the Housing Choice Voucher (HCV) component of the MTW Demonstration Program, we identified the following deficiencies. This condition is a repeat of prior year finding 2024-005: 1. Melissa McCullum (port-out tenant): The tenant file did not contain the required HUD Form 50058 or the Enterprise Income Verification (EIV} documentation. As a result, the family's eligibility, income determination, and assistance could not be substantiated from the file. 2. Mark'elia Keyona Reaves: The Authority was unable to provide the HUD Form 50058; the form was not retained in the tenant file and only tenant balances from the Authority's housing software were available. The data is reportedly retrievable from HUD's IMS/PIC system but could not be reproduced from the Authority's records. 3. Deborah Waiters: The income determination was incorrect. Social Security income was not recalculated based on the prior-year recertification; although an updated Social Security benefit letter was received indicating a change in the monthly benefit, the income reported on the HUD Form 50058 was not updated accordingly, resulting in an inaccurate rent and housing assistance payment (HAP) calculation. Planned Corrective Action: The Authority concurs with the finding and questioned costs of $395,580.79 and acknowledges it is a repeat of finding 2024-005. Ensure Forms 50058 and supporting documentation are retained; recalculate household income when required; retrieve or reconstruct missing records; resolve questioned costs with HUD; conduct file reviews; and prcvide staff training. Timeline for completion: 6 months

Title: Inadequate Tenant File Documentation in Public Housing Program Name: Moving to Work Demonstration Program - Public Housing ALN: 14.881 Description: During tenant file testing for the Public Housing component of the MTW Demonstration Program, food stamp (SNAP) income was not fully excluded from the annual income calculations for three tenants. In addition, the Authority was unable to locate the entire tenant file, including all required compliance documentation, for one additional tenant. Planned Corrective Action: The Authority will review and correct the affected income determinations to ensure that food stamp (SNAP) benefits are properly excluded from tenant annual income, with corrections to be reflected at the December 2026 annual recertification. The Authority will reconstruct or obtain the missing tenant file and will implement supervisory review over annual recertifications. Staff will receive training on income calculation and exclusion requirements, and periodic file reviews will be performed to verify completeness and accuracy.

The Department of Human Services (DHS) agrees with the findings, and we’ll work with the DCAS and DICM teams to mitigate the causes of the findings. These findings are mostly residual issues with the tables in DHS/ESA DCAS system. ESA needs to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. This would be automating the process by connecting the 2-step process into one task. This automation process would be a permanent solution to curbing stale and unsubstantiated hours from migrating to Q5i. DCWET will work with DICM to request that a JIRA ticket be created to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. The ESA DPO needs to conduct staff training (re-training) of all SSR on the DCAS screens which require action to confirm employment. This means that the DPO should dedicate resources to providing adequate training to SSRs involved in updating customers’ employment information in DCAS. The DCWET Deputy Administrator will take the lead with the DPO counterpart to implement the necessary training starting before September 30, 2027.

The BGCNEO accounting team and government grants team will develop and maintain a shared drive to securely store all required eligibility forms and supporting documentation. Prior to submitting grant billings, BGCNEO accounting staff will review the shared drive to ensure all billed participants have the appropriate documentation on file and have received approved eligibility determination from the funder.

Recommendation: The Department of Social Services should strengthen internal controls over performance and special reporting for the Money Follows the Person Rebalancing Demonstration to ensure it maintains data to support figures reported to the Department of Health and Human Services. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding and is taking steps to strengthen internal controls over performance monitoring and special reporting for the Money Follows the Person (MFP) Rebalancing Demonstration. DSS is implementing a secure SharePoint repository to centrally maintain, organize, and track all documentation supporting the MFP Work Plan and the MFP Semi-Annual Report. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Christine Weston, Program Division Director (860) 424-5012

Management acknowledges the auditors’ review of HUD HOME eligibility testing. We believe our current processes generally comply with HUD requirements; however, we recognize the opportunity to strengthen controls. To address the auditors’ comments, we will enhance our eligibility verification procedures, improve documentation consistency, and provide additional staff training. These corrective actions will help ensure ongoing compliance and accuracy in eligibility determinations. Personnel Responsible for Implementation: Meredith Elguira Position of Responsible Personnel: Community Development Director Expected Date of Implementation: April 30, 2026

Health Center Program – Assistance Listing No. 93.224 Recommendation: We recommend the organization enhances its current process related to the preparation of the UDS report and reinforce the requirement to maintain documentation to support the amounts reported within the various tables within the UDS report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will continue to maintain supporting documentation for our UDS submissions, to include any emails between the reviewer and FCC staff members in regards to questioned amounts and recommended reclassifications. Dental records, which are produced from a separate EMR system and require manual compilation, will be included with our UDS supporting records. Name(s) of the contact person(s) responsible for corrective action: Jennifer A. Breedlove Planned completion date for corrective action plan: March 31, 2026

Finding 2025-003 – Incomplete Eligibility Documentation Management agrees with the recommendation and will implement stronger processes to ensure that records confirming the eligibility of program participants are obtained and properly maintained. Specifically, all program staff documenting client eligibility will receive related training on eligibility requirements and best practices for related recordkeeping. While the organization will take these steps to help prevent reoccurrence of this finding, management also states that it directly sought and followed guidance from the program pass-through entity specific to client eligibility which was deemed in this audit to be inconsistent with requirements guiding the federal program. At the time of writing, this matter is being evaluated by the pass-through entity with further guidance forthcoming. Therefore, in addition to the steps outlined above, the organization will also further verify any guidance received from pass-through entities or other monitoring agencies to ensure its internal processes align directly and specifically with all requirements of the federal program. The contact persons for the Corrective Action Plan are Bill Threlkeld, VP of Community Resources Partnerships; Ted Lewis, EVP of Operations and Information Technology (IAT Co-Chair); and Aaron Hernandez, Sr. Director, Finance (IAT Co-Chair). The anticipated completion date is June 30, 2026. In addition to these specific steps, Cornerstones has strengthened its compliance review operations overall through the addition of a staff member who will focus primarily on compliance issues across the organization. Cornerstones has also formed an Internal Audit Team (IAT) comprised of organizational leadership that will provide objective assurance that the organization operates in full alignment with laws, regulations, contract provisions, and ethical standards.

Finding 2025-002 –Missing Records (Repeat Finding 2024-002) Management agrees with the recommendation and will implement stronger review processes to ensure proper documentation is in place to support pay-for-performance outputs and outcomes. Specifically, all program staff providing client charting and documentation will receive related training, both internally as well as from identified external sources. Accordingly, program staff attended a training on case management provided by an external partner in November 2025. In addition, a Case Manager Case Note Template has been developed that specifically outlines documentation required to support pay-for-performance outputs and outcomes including client intake, goals, activities and progress, and outcomes, as well as best practices for documenting client services. Finally, the organization will work with its external partners (PTEs, monitoring agencies, etc.) to ensure that requirements are consistently stated across all pertinent organizations and described in common nomenclature to avoid confusion and/or inadvertent omissions, which have been key factors contributing to the reoccurrence of this finding in FY25. The contact persons for the Corrective Action Plan are Lacy Stokes, VP of Family Empowerment and Self-Sufficiency; Ted Lewis, EVP of Operations and Information Technology (IAT Co-Chair); and Aaron Hernandez, Sr. Director, Finance (IAT Co-Chair). The anticipated completion date is May 31, 2026.

Finding 2025-001 – Incomplete Eligibility Documentation (Repeat Finding 2024-001) Management agrees with the recommendation and will implement stronger processes to ensure that records confirming the eligibility of program participants are obtained and properly maintained. Specifically, all program staff documenting client eligibility will receive related training, both internally as well as from identified external sources. Accordingly, program staff attended a training on case management provided by an external partner in November 2025. Internal training will center on the Employment and Training Eligibility Determination form developed by the program pass-through entity in March 2026. This document provides a detailed checklist of the specific information required to verify client eligibility prior to delivering program services. Finally, the organization will work with its external partners (PTEs, monitoring agencies, etc.) to ensure that requirements are consistently stated across all pertinent organizations and described in common nomenclature to avoid confusion and/or inadvertent omissions, which have been key factors contributing to the reoccurrence of this finding in FY25. The contact persons for the Corrective Action Plan are Lacy Stokes, VP of Family Empowerment and Self-Sufficiency; Ted Lewis, EVP of Operations and Information Technology (IAT Co-Chair); and Aaron Hernandez, Sr. Director, Finance (IAT Co-Chair). The anticipated completion date is May 31, 2026.

FINDING 2025-005 Finding Subject: Contact Person Responsible for Corrective Action: Tracey Haas, Business Manager Contact Phone Number and Email Address: 219-873-2000 x 8346 thaas@mcas.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will implement a system of internal controls to ensure allowable costs are documented and that receive board approval for all pay rates moving forward. However, we disagree with the finding on the allowable costs pertaining to the Financial Consulting Claims. We wrote them into the grant, and the grant was approved. There was also no Business Manager or Chief Financial Officer in place during the pandemic, resulting in the need for the consulting firm. Anticipated Completion Date: We anticipate that this correction will be in place by July 2026.

SWN will develop additional review procedures over contracts to ensure proper adjustments are proposed to allocate expenses between proper periods. Procedure for approval of the Finance Committee by May 21, 2026. This procedure may include implementation of official listing of SWN's written contracts and vendor contracts. Additionally, the Organization plans to work with vendors to align contracts with the fiscal reporting period.

2025-102 The County did not develop internal control procedures over program reporting and cash management requirements, increasing risk of report errors to awarding agencies and wrongly receiving monies Cluster Name: Workforce Innovation and Opportunity Act (WIOA) Cluster Assistance Listings numbers and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Award Numbers and years: IGA DI21-002286 July 1, 2024 through June 30, 2025 IGA DI23-002389 July 1, 2023 through June 28, 2028 Assistance Listings numbers and program name: 21.027 COVID-19—Coronavirus State and Local Fiscal Recovery Funds Award Numbers and years: 1505-0271 March 3, 2021 through December 31, 2024 CT-FM-22-149 October 1, 2024 through September 30, 2025 SLFRFP1962 January 5, 2023 through December 31, 2026 CTR069300 January 1, 2024 through December 30, 2026 GTAW-FM-23*123 October 3, 2022 through July 3, 2026 ACJC-VC-25-001A July 1, 2024 through December 31, 2024 Assistance Listings numbers and program name: 93.268 Immunization Cooperative Agreements Award numbers and years: CTR062571 July 1, 2022 through June 30, 2025 CTR059891 July 1, 2022 through June 30, 2027 Name of contact person: Art Cuaron, Director, Finance and Risk Management Anticipated completion date: June 30, 2027 The County recognizes the need to strengthen internal controls over federal reporting and cash management requirements. F&RM will complete the following actions to ensure compliance with 2 CFR Part 200: 1. Establish written internal control policies and procedures for federal program reporting. All federal financial reports will undergo an independently documented review before submission to ensure accuracy, allowability, and proper reporting periods. 2. Implement documentation standards requiring staff to retain supporting materials such as system reports, financial queries, screenshots, and reconciliations, in accordance with federal and County retention requirements. 3. Pima County has been working with each of its grant implementing entities to use Euna Grants calendaring and reminders to prompt the entities’ timely reporting activities. Grants Management and Innovation (GMI) Department sets the reminders schedule at the onset of the performance period. The reminders are then automatically emailed to the grants manager and the assigned accountant for each grant on a set schedule throughout the course of the grant. GMI and Finance – Grants will continue to work with grant implementing entities to use these reminders to trigger the necessary actions in a timely manner. Pima County was still in the process of institutionalizing this system during FY25. 4. Provide training for staff who prepare and review federal reports, focusing on reporting requirements, documentation standards, internal controls, and record retention. 5. Conduct periodic management oversight reviews to confirm that internal controls are followed and that reports are complete, accurate, and submitted on time. The County is also planning to implement the Workday Grants Module with an anticipated go-live of July 1, 2027. This solution will enhance our ability to manage the full fiscal lifecycle of grant awards and ensure compliance with federal reporting requirements. The Workday Grants Module is a native Workday solution, purpose-built to support the full fiscal grant lifecycle. The module supports the following financial grant objectives: • Grant setup and award and fiscal tracking • Cost allocation and allocability controls • Real-time grant financial reporting • Compliance with federal Uniform Guidance (2 CFR 200) • Integration with Workday Financial Management, Procurement and Human Capital Management (HCM) In addition, F&RM has submitted FY 2026/27 budget requests to fund three additional Accountant III positions in our Finance – Grants Division. These positions will expand our capacity to manage our grant portfolio and strengthen our reconciliation, billing and SEFA preparation processes. The contract for the Workday Grants Module is scheduled to go before the Board of Supervisors for approval in April. These new positions will be included in the County Administrator’s Recommended Budget and will be considered by the Board as part of the full budget adoption process in June.

Recommendation: The Department of Social Services should strengthen internal controls over performance and special reporting for the Money Follows the Person Rebalancing Demonstration to ensure it maintains data to support figures reported to the Department of Health and Human Services. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding and is taking steps to strengthen internal controls over performance monitoring and special reporting for the Money Follows the Person (MFP) Rebalancing Demonstration. DSS is implementing a secure SharePoint repository to centrally maintain, organize, and track all documentation supporting the MFP Work Plan and the MFP Semi-Annual Report. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Christine Weston, Program Division Director (860) 424-5012

Corrective Action Plan: The Department agrees with the finding and already has a plan underway to resolve the issues. ODM has been working with the Ohio Medicaid Enterprise System Fiscal Intermediary (FI) vendor to document the Third Party Liability (TPL) process and identify needed system updates, including importing electronic historical evidence into the FI module and creating new system panels that make TPL information easier for staff to view and work with. Thirteen TPL-related system updates have been identified; eight are already in progress and nearly complete. Once these updates are finished, TPL data including archived historical information will be accessible directly in FI in a familiar format. The Centers for Medicare and Medicaid Services requires states to use commercial off-the-shelf (COTS) products and rely on default tools whenever possible. The FI system initially lacked a data structure that could store all historical TPL information in an accessible way. Because the COTS system does not use the same tracking fields as the prior system, some historical evidence such as Document Control Numbers (DCNs) or supporting insurance documentation could not be viewed in FI during the audit period. ODM is adding new panels and data fields so this historical information can be accessed more easily going forward. TPL is complex, and due to the FI system limitations, monitoring is currently a manual process. The ODM TPL Unit Manager continues to review a sample of verifications to ensure insurance information is accurate and correctly captured in FI. The manager maintains a spreadsheet documenting TPL activity, with all relevant recipient information except the DCN (which is not available in FI). The TPL Unit manually removes or end dates TPL coverage in FI and sends a file to the vendor each week to add TPL information to the Other External Enrollment panel. The Department will take necessary steps to ensure all relevant data elements and documentation are maintained and accessible when major system upgrades or replacements occur, including appropriate retention of historical data. Anticipated Completion Date for Corrective Action: July 2026 Contact Person Responsible for Corrective Action: Name: Megan Powell Title: Audit Remediation Manager Address: 50 West Town Street, Suite 400, Columbus, Ohio 43215 Phone Number: 614-752-3844 E-Mail Address: megan.powell@medicaid.ohio.gov